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Buccal nitrates in left ventricular failure

Three Part Question

[In a patient with left ventricular failure] are [buccal nitrates equivalent to a nitrate infusion] for [preload reduction]?

Clinical Scenario

You are called to see a 60 year old man who has been increasingly breathless for a week. Examination reveals him to be mildly dyspnoeic at rest with a raised JVP and bibasal creps. There is evidence of ischaemia on his ECG. The CXR shows upper lobe diversion and Kerley B lines. You wonder whether buccal suscard would be an appropriate alternative to a GTN infusion.

Search Strategy

Medline 1966-04/03 using the OVID interface.
[(exp nitrates OR OR exp nitroglycerin OR OR exp vasodilator agents OR OR glyceryl OR exp isosorbide dinitrate OR OR AND {( OR exp mouth mucosa OR exp administration, buccal) AND (exp injections, intravenous OR OR} AND (exp heart failure, congestive OR heart OR OR left ventricular OR congestive cardiac OR exp ventricular dysfunction, left OR exp ventricular dysfunction OR exp pulmonary oedema)] LIMIT to human AND English language.

Search Outcome

Altogether 7 papers were found, of which 5 were reviews of nitrates rather than comparative studies. The 2 remaining publications consisted of a summary report and full article relating to the same trial. the results of this trial are shown in the table.

Relevant Paper(s)

Author, date and country Patient group Study type (level of evidence) Outcomes Key results Study Weaknesses
Verma SP et al,
36 male patients with acute LVF secondary to recent MI (<10 hours) in CCU IV vs buccal vs transdermal GTN Average doses over 90 mins: IV 12.9mg, buccal 5mg, dermal 20mgPRCTLeft heart filling pressuresAll three groups reducedOnly 36 patients Different doses of buccal, IV and dermal GTN (based on previous studies) IV dose individually titrated; buccal and dermal doses predetermined
Cardiac outputNo reduction in any group
BP3 patients had BP falls in buccal group but with no clinical deterioration


There is very limited evidence available to allow direct comparison between intravenous and buccal routes.

Clinical Bottom Line

Buccal nitrates produce an immediate reduction in preload (comparable with intravenous GTN).


  1. Verma SP, Silke B, Reynolds GW et al. Nitrate therapy for left ventricular failure complicating acute myocardial infarction: a haemodynamic comparison of intravenous, buccal and transdermal delivery systems. J Cardiovasc Pharmacol 1989;14(5):756-762.